While nearly 25 percent of Americans who die each year spend the final days or months of life in a nursing home (NH), the experience of dying in NHs is often far less than optimal. Research has shown hospice care provided to NH residents is associated with higher quality EoL care, with fewer hospitalizations and with less use of invasive treatments. In 2000, three of four NHs provided EoL care in partnership with hospice providers; however, there was substantial variation across U.S. states in the proportion of NHs who partnered with hospice as well as in the proportion of NH residents who enrolled in hospice prior to death, and this variation appeared to be associated with differing state regulations and Medicaid reimbursement policies. Unavailable presently are estimates on how NH contracting and hospice access in NHs have changed over time as well as estimates of how NH residents' use of hospice has changed over time (i.e., use of the higher levels of hospice care [hospice general inpatient and continuous care] and median length of hospice stays). Also unknown is how changes in state regulations and Medical NH payment policies and practices are associated with observed longitudinal changes in hospice contracting, access and use. This study proposes to use newly collected longitudinal data on relevant state regulations and Medicaid NH reimbursement policies and practices from 1999 through 2004 linked to NH resident assessment (MDS) data (1999 through 2005) and to Medicare denominator and hospice claims data to document changes in NH hospice contracting and NH residents' access to and use of Medicare hospice and to test the association between changes in state policies and changes in hospice contracting, access and use. The specific aims of this proposal are to, within the 48 contiguous U.S. states: 1. a) Estimate and describe the proportion of NHs contracting with Medicare hospice providers in calendar years 1999-2005; and, b) test whether rates of contracting changed following changes in key state policies/practices. 2. a) Estimate and describe, 1) the proportion of NH residents who access Medicare hospice prior to death in calendar years 1999 through 2005 and 2) how access differs by gender, race/ethnicity, and diagnosis (cancer vs. non-cancer); and, b) test whether the proportion of NH residents accessing hospice changed following changes in key state policies/practices. 3. a) Estimate and examine NH residents' use of Medicare hospice (median length of hospice stay and proportion of hospice days for hospice inpatient and continuous care) in calendar years 1999 through 2005; and, b) test whether hospice median lengths of stay and the proportion of hospice days for hospice inpatient care and continuous care changed following changes in key state policies/practices. In the longer-term, the intent of this research agenda is to positively influence state policy through state-level intervention aimed at improving the quality of EoL care in NHs; it addresses AHRQ's priority area of "Payment and Organization" and the priority population of individuals needing EoL care. [unreadable] [unreadable] [unreadable]